“TO STUDY THE MORTALITY PREDICTION OF ICU PATIENTS WITH PERFORATION PERITONITIS, REQUIRING EMERGENCY LAPAROTOMY’’
Main Article Content
Keywords
SICU, emergency laparotomy, perforation peritonitis.
Abstract
Introduction- Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It’s the primary cause of death from infection, especially if not recognized and treated promptly. It’s a syndrome caused by pathogen factors and host factors with characteristics that evolve over time. What differentiates sepsis from infection is an aberrant or dysregulated host response and the presence of organ dysfunction. The clinical and biological phenotype of sepsis can however be modified by preexisting acute illness, long-standing co-morbidities, medication, and interventions.
Aims and objectives- ‘’to study the mortality prediction of ICU patients with perforation eritonitis, requiring emergency laparotomy’’
Methods and materials- This is a prospective cohort study done in a tertiary care center in central India ‘’
conducted in the department of General Surgery Department of Surgery in people’s college of medical science and research Centre, Bhopal for two-year study in 50 patients. Surgical Abdominal Sepsis admitted in surgical intensive care unit (SICU) during study period, for two years.
Inclusion criteria– All the patients ≥16 years of age admitted in SICU, as a result of perforation peritonitis requiring exploratory laparotomy and willing to participate in the study after written informed consent were included. Age<16years and patient with Sepsis secondary to trauma, Laparotomies for non-septic indications are excluded from study.
After obtaining Ethical clearance from Institute’s Ethical Committee, all the patients fulfilling the inclusion criteria were enrolled in the study. Written consent was obtained from all the study participants. The participants were divided in two groups i.e. survivors and non survivors based on their outcome.
Results- -Mean age of patients in present study was 36±16.14 years. In the present study 42(84%) out of 50 patients were males while 8(16%) were females. All 5 patients who died were males. Most common etiology of SABS was small intestine perforation (36%) followed by gastric perforation (26%). Mean Apache score was maximum in intra-abdominal abscess (105) followed by ischemia (57) and gastric perforation and was minimum in large intestine perforation (29.3). Mean of MAP of 45 patients in survivor group was 82.55 mmHg while the same in non-survivors was 75 mm Hg. Mechanical ventilation was used in total of 3 patients, out of which 1 survived and 2patients succumbed to death. The association of mechanical ventilation usage with mortality (chi square test) amongst survivors and non survivors was found to be statistically significant (p=0.0008).
Deranged Sodium was seen in 11 out of 45 survivors (24.4%) and 2 out of 5(40%) non-survivors. The survivors had a mean urine output of 1020 ml and non-survivors had a mean urine output of 350 ml. In case of serum creatinine; mean of survivor group was 0.98 while in non-survivors is1.74. Mean albumin in survivor group was 3.09mg/dl and in non-survivors was1.94. In present study, 12 patients had APS score less than 30 with no mortality. 1 out of 31 patients in 30-60 score range died while 4 out of 7 died in case of score >60. A receiver operating characteristic (ROC) curve, comparative analysis of the mortality predictions with APACHE IV is done and shows AUC =0.911 and p <0.001. Thus, shows the high predictive efficacy of APACHE IV score. The mean observed length of stay of all patients was 6.65 days against an expected LOS (length of stay) of 4.6 days. Overall O:E Ratio was 1.44 against O:E of 1.21 in non-survivors with observed and expected LOS of 10.2 and 8.42 days. The difference was statistically significant with p value =0.02.
Conclusion- From this study we concluded that, results in terms of Length of stay are not accurate and a further work upon the same is required. Results of the study may be improved if sample size was bigger.
Hence, a larger study with greater sample size and if possible, involvement of multiple centers is recommended which could help in reaching some conclusive and milestone results.
From this study we evaluate the mortality of ICU patients with perforation peritonitis requiring emergency laparotomy, which is essential for all healthcare workers
References
2. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Critical care medicine. 1985;13(10):818-29.
3. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, Sirio CA, Murphy DJ, Lotring T, Damiano A, Harrell Jr FE. The APACHE III prognostic system: risk prediction of hospital mortality for critically III hospitalized adults. Chest. 1991;100(6):1619-36.
4. Knaus WA, Zimmerman J E, Wagner DP, Draper EA, Lawrence DE.APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Critical care medicine. 1981;9(8):591-7.
5. Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unit length of stay: Bench marking based on Acute Physiology and Chronic Health Evaluation (APACHE)IV. Critical caremedicine.2006;34(10):2517-29.
6. Hanisch E, Brause R, Paetz J, Arlt B. Review of a large clinical series: predicting death for patients with abdominal septic shock. Journal of intensive care medicine. 2011;26(1):27-33.
7. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS. The third international consensus definitions for sepsis and septic shock (Sepsis-3).Jama.2016;315(8):801-10.
8. Lipinska-Gediga M. Coagulopathyinsepsis—a new look at an old problem. Anaesthesiology intensive therapy.2016;48(5):352-9.
9. Marik PE, Taeb AM. SIRS, qSOFA and new sepsis definition. Journal of thoracic disease. 2017;9(4):943.
10. Friedman G, Silva E, Vincent JL. Has the mortality of septic shock changed with time?. Critical care medicine. 1998;26(12):2078-86.
11. Leppäniemi A, Kim ball EJ, Malbrain ML, Balogh ZJ, De Waele JJ. Management of abdominal sepsis—aparadi gm shift?.Anaesthesiology intensive therapy. 2015;47(4):400-8.
12. Pieracci FM, Barie PS. Management of severe sepsis of abdominal origin. Scandinavian journal of surgery.2007;96(3):184-96.
13. Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM Population burden of long‐term survivorship after severe sepsis in older Americans. Journal of the American Geriatrics Society. 2012;60(6):1070-7.
14. Dahhan T, Jamil M, Al-Tarifi A, Abouchala N, Kherallah M. Validation of the APACHE IV scoring system in patients with severe sepsis and comparison with the APACHEIIs ystem. Critical Care. 2009;13(1):P511.
15. Le Gall JR, Leme show S, Saulnier F. A new simplified acute physiology score (SAPSII) based on a European /North American multi center study. Jama. 1993;270(24):2957-63.
16. Kirkpatrick AW, Coccolini F, Ansaloni L, Roberts DJ, Tolonen M, McKee JL, Leppaniemi A, Faris P, Doig CJ, Catena F, Fabian T. Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis(the COOL trial): study protocol for a randomized controlled trial. World Journal of Emergency Surgery. 2018;13(1):26.
17. Papavramidis TS, Marinis AD, Pliakos I, Kesisoglou I, Papavramidou N.Abdominal compartment syndrome–Intra-abdominal hypertension: Defining, diagnosing, andmanaging. Journal of emergencies, traumaandshock.2011;4(2):279.
18. Strik C, Stommel MW, Schipper LJ, van Goor H, ten Broek RP. Risk factors for future repeat abdominal surgery. Langen beck's archives of surgery. 2016; 401(6):829-37.
19. Mehrez A, Gafni A. Preference Based Out come Measures for Economic Evaluation of Drug Interventions. Pharma coeconomics1992; (5):338-45.
20. Gunning K, Rowan K. O utome dataand scoring systems. Bmj. 1999; 319 (7204):241-4.
21. Rapsang A G, Shyam DC. Scoring systems in the intensive care unit: a compendium. Indian journal of critical care medicine: peer-reviewed, official public cation of Indian Society of Critical CareMedicine.2014;18(4):220.
22. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Critical care. 2010; 14(2): 207.
23. Becker RB, Zimmerman JE. ICU scoring systems allow prediction of patient outcomes and comparison of ICU performance. Critical care clinics. 1996; 12(3):503-14.
24. Vincent JL, Marshall JC, Ñamendys-Silva SA, François B, Martin-Loeches I, Lipman J, Reinhart K, Antonelli M, Pickkers P, Njimi H, Jimenez E. Assessment of the worldwide burden of critical illness: the intensive care over nations(ICON)audit. lancet Respiratory medicine. 2014;2(5):380-6.
25. Bota DP, Mel ot C, Ferreira FL, Ba VN, Vincent JL. The multiple organ dys function score (MODS) versus the sequential organ failure assessment (SOFA) score in outcome prediction. Intensive caremedicine.2002;28(11):1619-24.
26. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter P, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score todes cry be organ dysfunction/failure.
27. Simalti AK, Ghuliani R,N air BT. Update on Changing Terminologies in Sepsis. Journal of Nepal Paediatric Society. 2016;36(2):178-83.
28. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today’s critically ill patients. Critical care medicine. 2006;34(5):1297-310.
29. Bhattacharyya M, Todi S. APACHE IV: benchmarking in an Indian ICU. Critical Care. 2009;13(1):P510
30. Anderson ID, Fearon KC, Grant IS. Laparotomy for abdominal sepsis in the critically ill. British journal of surgery. 1996;83(4):535-9.
31. McLauchlan GJ, Anderson ID, Grant IS, Fearon KC. Outcome of patients with abdominal sepsis treated in an intensive care unit. British journal of surgery.1995;82(4):524-9.
32. Chan T, Bleszyns ki MS ,Buczkows ki AK .Evaluation of APACHE-IV predictive scoring in surgical abdominal sepsis: a retrospective cohort study.JCDR.2016;10(3):16.
33. Ghorbani M, Ghaem H, Rezaianzadeh A, Shayan Z, Zand F, Nikandish R. A study on the efficacy of APACHE-IV for predicting mortality and length of stay in an intensive care unit in Iran. IJS. 2017;6(2).
34. Orsini J, Blaak C, Yeh A, Fonseca X, Helm T, Butala A, Morante J. Triage of patients consulted for ICU admission during times of ICU – bed shortage. Journal of clinical medicine research. 2014; 6(6):463.
35. Knaus WA, Draper EA, Wagne rDP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Annals ofInternalMedicine.1986;104(3):410-8.
36. Vijay Ganapathy S, Karthikeyan VS, Sreenivas J, Mallya A, Keshava murthy
37. R. Validation of APACHE II scoring system at 24 hours after admission as aprognostic tool in urosepsis: A prospective observational study. Investigative and clinical urology. 2017; 58(6): 453-9.
38. Sadaka F, Ethmane Abou ElM aali C, Cytron MA, Fowler K, Javaux VM, O’Brien J. Predicting Mortality of Patients With Sepsis: A Comparison of APACHE II and APACHE III Scoring Systems. Journal of clinical medicine research.2017;9(11):907.
39. Shoukat H, Muhammad Y, Gondal KM, AslamI. Mortality prediction in patients admitted in surgical intensive care unit by using APACHE IV. J CollPhysicians Surg Pak. 2016 ;26 (11):877-0.
40. Vishwani A, Gaikwad VV, Kulkarni RM, Murchite S. Efficacy of POSSUMScoring System in Predicting Mortality and Morbidity in Patients o Peritonitis Under going Laparotomy. Int J Sci Stud.2014;2(4):29-36.
41. Chabot E, Nirula R. Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management. Trauma surgery & acute care open. 2017;2 (1):e 000063.
42. Martin ND, Patel SP, Chreiman K, Pascual JL, Braslow B, Reilly PM, Kaplan L J. Emergency Laparotomy in the Critically Ill: Futility at the Bedside. Critical care research and practice. 2018.
43. Loftus TJ, Bihorac A, Ozrazgat- Baslanti T, Jordan JR, Croft CA, Smith RS, E fron PA, Moore FA, Mohr AM, Brakenridge SC. Acute kidney injury following exploratory laparotomy and temporary abdominal closure. Shock.2017;48(1):5-10.
44. El-Naggar TA, Raafat RH, Mohamed SA. Validity of three scoring systems in assessing the severity and outcome in Al-Abbassia Chest Hospital Respiratory Intensive Care Unit patients. Egyptian Journal of Broncho logy .201812(2):208.
45. Saleh A, Ahmed M, Sultan I, Abdel-Lateif A. Comparison of the mortalityprediction of different ICU scoring systems (APACHE II and III, SAPS II, andSOFA) in a single-center ICU subpopulation with acute respiratory distress syndrome. Egyptian journal of chest diseases and tuberculosis. 2015; 64(4):843-8.
46. Yamin S, VASWANI AK, AFREEDI M. Predictive efficacy of APACHEIV at ICU. sof CHK. Pakistan Journal of Chest Medicine.2011;17(1).
47. Ayazoglu TA. A comparison of APACHEII and APACHEIV scoring systems in predicting outcome in patients admitted with stroke to an intensive care unit. Anaesthesia, Pain & Intensive Care. 2011;15(1).
48. Lee H, Shon YJ, Kim H, Paik H, Park HP. Validation of the APACHE IV model and its comparison with the APACHE II, SAPS 3, and Korean SAPS 3models for the prediction of hospital mortality in a Korean surgical intensive care unit. Korean journal of anesthesiology.2014;67(2):115-22.
49. Kuzniewicz MW, Vasile vskis EE, Lane R, Dean ML, Trivedi NG, Rennie DJ, Clay T, Kotler PL, Dudley RA. Variation in ICU risk-adjusted mortality: impact of methods of assessment and potential confounders. Chest. 2008; 133(6):1319-27.
50. Chelluri L, Grenvik A, Silverman M. Intensive care for critically ill elderly: mortality, costs, and quality of life: review of the literature. Archives of Internal Medicine. 1995;155(10):1013-22.
51. Chattopadhyay A, Chatterjee S. Predicting ICU length of stay using APACHE-IV in persons with severe sepsis– apilot study. Journal of Epidemiological Research. 2015
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
Dr. Ravi Pratap Singh
Department Of Anaesthesiology, King George’s Medical University, Lucknow, UP
Dr. Anil Dawar
Assistant Professor, Department Of General Surgery, Dr Laxmi Narayan Pandey GMC Ratlam
Dr. Vikram Singh Mujalde
Associate Professor, Department Of General Surgery, Dr. Laxmi Narayan Pandey, GMC Ratlam Mp
Dr. Pramod Pandey
Department Of Anaesthesiology, King George’s Medical University, Lucknow, UP